David Bernard
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MIAMI BEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRA nON FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
City Manager or any city board or committee; or any action, decision or recommendation of any city personnel during the time
period of the entire decision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed
by the city commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST:
(Last) (First)
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BUSINESS NAME AND ADDRESS (Number and Street) I (City)
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FAX NUMBER:
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EMAIL:
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TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street)
(City)
(State)
(Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
V C/It
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER):
10
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
I' 0
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
DYes
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes ~o: Are YOU 10bbyinQ on a pendinQ application for a Development AQreement with the City or
application for chanQe of zoninQ map desiQnation or chanQe to the City's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of a not-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees,.
D Yes ~o: Are YOU representinQ a not-for-profit corporation or entity without special compensation
or reimbursement.
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMI TO THE CITY
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITUR , AS WELL A COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDIN CALENDAR YE R. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO PENDITUR OR COMPENS ION DURING THE
REPORTING PERIOD.
Signature of Lobbyist:
Signature of Principal/Client:
V. SIGNATURE UNDER OATH:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
. [1/produced IDr])~8fo53 -/100.... 7)....2-~~~U~d ID f])L4F 'Bfo53-ibo-7S-- 2..0"8- 0
Form of Identification Form of Identification
D Personally known (Lobbyist)
D Personally known (Principal)
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;:::::::::::.--
State of Florida, County of Miam"
Sworn and subscribed before m
This _day of , 20
LIlliAN BEAUCHAMp
MY COMMISSION # DO 5304
B~xprRES: Apri/29, 2010 16
111m Notary PUll/ic UI1deIWritSIS
VII. SIGNATURE AND STAMP OF NOTARY:
Signature of Public Notary - State of Florida
Notarization of Principal's signature
FOR CLERK'S USE ONLY Q ~ I AI__
Annual Registration fee: [ .h'es [ ] No Amoufl.!:~.i I EC) MeR # 28f-t(rj':;> Date Paid ~
Lobbyist Registration Form ){~ei'~ed and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM O~ Revised 12/08/04